1. A nurse is caring for a patient with severe dehydration. Which of the
following is the most appropriate first intervention?
A. Administer an oral electrolyte solution
B. Insert an intravenous (IV) line and administer normal saline
C. Encourage the patient to drink water
D. Monitor vital signs every 4 hours
Answer: B. Insert an intravenous (IV) line and administer normal saline
Rationale: Severe dehydration requires immediate IV fluid resuscitation,
particularly with isotonic solutions like normal saline. Oral fluids may
not be sufficient or safe in a patient with severe dehydration or in cases
of altered mental status.
2. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is receiving oxygen therapy. The nurse notes that
the client’s respiratory rate is decreasing, and their oxygen saturation
is rising above 95%. Which action should the nurse take?
A. Increase the oxygen flow rate
B. Assess the client’s respiratory status and report findings to the
healthcare provider
C. Continue to monitor the client
D. Decrease the oxygen flow rate
Answer: B. Assess the client’s respiratory status and report findings to
the healthcare provider
Rationale: COPD patients often have a blunted respiratory drive due to
chronically elevated carbon dioxide levels. A decrease in respiratory rate
and increase in oxygen saturation could indicate hyperoxia, which can
,lead to respiratory depression. The nurse must assess the client and
notify the healthcare provider.
3. A nurse is teaching a patient with hypertension about lifestyle
modifications. Which of the following should the nurse include as a
recommendation to help lower blood pressure?
A. Increase daily sodium intake
B. Engage in moderate-intensity aerobic activity
C. Drink at least 3 cups of caffeinated beverages daily
D. Limit fluid intake to less than 1 liter per day
Answer: B. Engage in moderate-intensity aerobic activity
Rationale: Regular physical activity can help lower blood pressure by
improving heart function and reducing vascular resistance. Increasing
sodium intake and limiting fluids are not appropriate for managing
hypertension, and excessive caffeine may elevate blood pressure.
4. A nurse is caring for a postoperative client who has a Jackson-Pratt
drain in place. The nurse notes that the drainage is serosanguineous.
Which of the following actions should the nurse take?
A. Immediately report this to the healthcare provider
B. Empty the drain and measure the output
C. Increase the level of suction on the drain
D. Change the drain dressing
Answer: B. Empty the drain and measure the output
Rationale: Serosanguineous drainage (a mixture of blood and serous
fluid) is normal during the early postoperative phase. The nurse should
monitor the drainage output, empty the drain, and measure it to assess
, for any changes or complications. There is no immediate need to report
to the healthcare provider unless the amount significantly increases.
5. A nurse is providing care for a client with a stage 2 pressure ulcer.
Which of the following interventions should the nurse implement
first?
A. Administer prescribed pain medication
B. Cleanse the wound with hydrogen peroxide
C. Apply a hydrocolloid dressing
D. Increase protein intake
Answer: A. Administer prescribed pain medication
Rationale: Pain management is a priority for comfort before any
invasive procedures or wound care. After pain relief, the nurse can clean
the wound and apply dressings. Cleansing with hydrogen peroxide is not
recommended as it can damage healthy tissue.
6. A nurse is caring for a client with a history of heart failure who is
receiving digoxin. Which of the following signs and symptoms should
alert the nurse to possible digoxin toxicity?
A. Bradycardia and visual disturbances
B. Hyperkalemia and nausea
C. Tachycardia and vomiting
D. Hypertension and confusion
Answer: A. Bradycardia and visual disturbances
Rationale: Digoxin toxicity can cause bradycardia, confusion, and visual
disturbances (such as seeing halos). The nurse should assess for these
symptoms and notify the healthcare provider.
following is the most appropriate first intervention?
A. Administer an oral electrolyte solution
B. Insert an intravenous (IV) line and administer normal saline
C. Encourage the patient to drink water
D. Monitor vital signs every 4 hours
Answer: B. Insert an intravenous (IV) line and administer normal saline
Rationale: Severe dehydration requires immediate IV fluid resuscitation,
particularly with isotonic solutions like normal saline. Oral fluids may
not be sufficient or safe in a patient with severe dehydration or in cases
of altered mental status.
2. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is receiving oxygen therapy. The nurse notes that
the client’s respiratory rate is decreasing, and their oxygen saturation
is rising above 95%. Which action should the nurse take?
A. Increase the oxygen flow rate
B. Assess the client’s respiratory status and report findings to the
healthcare provider
C. Continue to monitor the client
D. Decrease the oxygen flow rate
Answer: B. Assess the client’s respiratory status and report findings to
the healthcare provider
Rationale: COPD patients often have a blunted respiratory drive due to
chronically elevated carbon dioxide levels. A decrease in respiratory rate
and increase in oxygen saturation could indicate hyperoxia, which can
,lead to respiratory depression. The nurse must assess the client and
notify the healthcare provider.
3. A nurse is teaching a patient with hypertension about lifestyle
modifications. Which of the following should the nurse include as a
recommendation to help lower blood pressure?
A. Increase daily sodium intake
B. Engage in moderate-intensity aerobic activity
C. Drink at least 3 cups of caffeinated beverages daily
D. Limit fluid intake to less than 1 liter per day
Answer: B. Engage in moderate-intensity aerobic activity
Rationale: Regular physical activity can help lower blood pressure by
improving heart function and reducing vascular resistance. Increasing
sodium intake and limiting fluids are not appropriate for managing
hypertension, and excessive caffeine may elevate blood pressure.
4. A nurse is caring for a postoperative client who has a Jackson-Pratt
drain in place. The nurse notes that the drainage is serosanguineous.
Which of the following actions should the nurse take?
A. Immediately report this to the healthcare provider
B. Empty the drain and measure the output
C. Increase the level of suction on the drain
D. Change the drain dressing
Answer: B. Empty the drain and measure the output
Rationale: Serosanguineous drainage (a mixture of blood and serous
fluid) is normal during the early postoperative phase. The nurse should
monitor the drainage output, empty the drain, and measure it to assess
, for any changes or complications. There is no immediate need to report
to the healthcare provider unless the amount significantly increases.
5. A nurse is providing care for a client with a stage 2 pressure ulcer.
Which of the following interventions should the nurse implement
first?
A. Administer prescribed pain medication
B. Cleanse the wound with hydrogen peroxide
C. Apply a hydrocolloid dressing
D. Increase protein intake
Answer: A. Administer prescribed pain medication
Rationale: Pain management is a priority for comfort before any
invasive procedures or wound care. After pain relief, the nurse can clean
the wound and apply dressings. Cleansing with hydrogen peroxide is not
recommended as it can damage healthy tissue.
6. A nurse is caring for a client with a history of heart failure who is
receiving digoxin. Which of the following signs and symptoms should
alert the nurse to possible digoxin toxicity?
A. Bradycardia and visual disturbances
B. Hyperkalemia and nausea
C. Tachycardia and vomiting
D. Hypertension and confusion
Answer: A. Bradycardia and visual disturbances
Rationale: Digoxin toxicity can cause bradycardia, confusion, and visual
disturbances (such as seeing halos). The nurse should assess for these
symptoms and notify the healthcare provider.
